1-783 (Rev.

1-31-10)
Applicant Information Form
Privacy Statement
Authority: The FBI’s acquisition, preservation, and exchange of information requested by this form is generally authorized under 28 U.S.C. 534. Depending on the
nature of your application, supplemental authorities include numerous federal statutes, hundreds of state statutes pursuant to Pub. L. 92-544, presidential executive
orders, regulations and/or orders of the Attorney General of the United States, or other authorized authorities. Examples include, but are not limited to: 5 U.S.C.
9101; Pub. L. 94-29; Pub. L. 101-604; and Executive Orders 10450 and 12968. Providing the requested information is voluntary; however, failure to furnish the
information may affect timely completion or approval of your application.

Social Security Account Number (SSAN): Your SSAN is needed to keep records accurate because other people may have the same name and birth date. Pursuant
to the Federal Privacy Act of 1974 (5 U.S.C. 552a), the requesting agency is responsible for informing you whether disclosure is mandatory or voluntary, by what
statutory or other authority your SSAN is solicited, and what uses will be made of it. Executive Order 9397 also asks federal agencies to use this number to help
identify individuals in agency records.

Additional Information: The requesting agency and/or the agency conducting the application-investigation will provide you additional information pertinent to
the specific circumstances of this application, which may include identification of other authorities, purposes, uses, and consequences of not providing requested
information. In addition, any such agency in the federal executive branch has also published notice.

Applicant Information * Denotes Required Fields

* Last Name
* First Name
Middle Name 1
Middle Name 2

* Date of Birth
* Social Security Number

Phone Number
E-Mail
Applicant Home Address
* Address 1
Address 2
Address 3
* City
* State
* Postal (ZIP) Code
* Country
Mail Results to Address
Check here if results are to be mailed to the home address above
C/O: Attn:
Address 1
Address 2
Address 3
City
State
Postal (ZIP) Code Country

Payment Enclosed (please check appropriate box)

Cashier’s Check Money Order Credit Card Form
Reason for Request

Return Mail Options

FEDEX Account #
Prepaid Return EnvelopeEnclosed First-Class Mail

* Applicant Signature